Billing Compliance Auditor

Nicklaus Children's Health System; Miami (FL); On-site; USD 90,000 - 150,000; Full time

Job summary

Nicklaus Children's Health System is seeking an experienced Billing Compliance Auditor to review coding and documentation for professional and facility services. The role ensures compliance with federal, state, and local regulations and internal policies.

Key duties include conducting audits, validating E/M levels and CPT/ICD-10 usage, performing DRG reviews, and supporting RAC requests. Requires CPC/CCS/RHIA/RHIT and 7–10 years’ experience; EPIC proficiency is a plus.

Qualifications

• 7–10 years of experience in coding and auditing of professional fee and facility services.
• 7–10 years of experience with CMS and FL Medicaid regulations, including billing, coding and documentation rules.
• 2–4 years of experience with data mining audits.
• CPC/CCS/RHIA/RHIT certification required

Responsibilities

• Audits professional fee and facility services coding and documentation.
• Assesses E/M level, CPT, ICD-10, and modifiers per AMA and CMS guidelines.
• Performs DRG coding and clinical reviews for CMS/federal requirements.
• Conducts QA to ensure accuracy of billing to Federal and State payers.
• Analyzes outcomes to identify trends and high-risk areas; suggests CAPAs.
• Documents findings in case management system as part of CAPAs.
• Keeps knowledge up-to-date on national/local coding and billing decisions.
• Performs follow-up audits to ensure remediation of findings.
• Supports RAC requests and other external recoupment reviews.

Skills

Auditing

CMS regulations

Documentation accuracy

Education

CPC, CCS, RHIA, or RHIT certification

Bachelor's degree preferred

Tools

EPIC

Job description

Job Summary

Serves as a resource to the NCHS Billing Compliance Program and is responsible for auditing coding and documentation for professional fee and facility services to ensure compliance with federal, state and local regulations, and NCHS policies.

Description

Job Summary

Serves as a resource to the NCHS Billing Compliance Program and is responsible for auditing coding and documentation for professional fee and facility services to ensure compliance with federal, state and local regulations, and NCHS policies.

Job Specific Duties

• Conducts coding and documentation audits for professional fee and facility services.
• Conducts audits for validation of appropriate E/M level, CPT, and ICD-10, Modifier appropriateness according to current AMA and CMS guidelines.
• Conducts DRG coding and clinical reviews to verify the accuracy of coding, DRG assignment and clinical indicators in accordance with CMS / federal requirements.
• Conducts quality assurance activities to ensure the accuracy and integrity of billing submitted to Federal and State payers.
• Analyzes Billing Compliance review outcomes and proactively identifies trends and high-risk areas.
• Develops appropriate recommendations for Corrective and Preventative Action (CAPAs).
• Documents finding in the case management system as part of the CAPAs.
• Researches changes in national and local coding and billing coverage decisions: maintains current knowledge of appropriate billing procedures.
• Performs follow-up audits to ensure remediation of findings.
• Supports the review and analysis of Recovery Audit Contractors (RAC) requests and other external requests for recoupment.

Qualifications

Minimum Job Requirements

• CPC, CCS, RHIA, or RHIT certification required
• 7-10 years of experience in coding and auditing of professional fee and facility fee services
• 7-10 years of experience with CMS and FL Medicaid regulations, including billing, coding and documentation requirements
• 2-4 years of experience with conducting data mining audits

Knowledge, Skills, And Abilities

• Bachelor's Degree preferred.
• Experience with EPIC is preferred.
• Experience in conducting Hospital, Professional Fee Service billing and coding audits preferred.
• Able to work independently.
• Able to research, abstract and communicate federal, state and payer documentation, billing and coding rules and regulations.
• Ability to be flexible, multitask, and switch priorities as well as work comfortably in a deadline driven/productivity environment.
• Ability to prioritize, organize, plan, and implement services as well as handle multiple projects/problems simultaneously.
• Excellent written and verbal communication skills.
• Excellent time management and organization skills.
• Strong interpersonal, collaboration, and presentation skills.
• Able to use tact, diplomacy, discretion, and judgment.
• Able to maintain confidentiality of sensitive information.

Job

Professional

Department

COMPLIANCE-1000-910900

Job Status

Professional